Queries about prostate cancer
Dr Wrishi Raphael
Mr Jalil, a retiree from Chittagong was recently diagnosed with prostate cancer after a blood test and a biopsy at 80 years of age. His son, Mr Khalil, a 50 year old man had several queries for their family physician about prostate cancer. Mr Khalil inquired about the natural history of the disease, about the use of various surgical modalities for the tumours treatment and other investigations which may aid therapy.
Carcinoma of the prostate is more common among elderly people. Men older then 80 years are the ones most affected by this cancer. Prostate cancer is the second leading cause of death in USA after lung cancer. The primary tumour grows as a nodule and is locally invasive at the beginning. Like several other abdominal tumours, prostrate cancer is capable of spreading to distant organs via lymph node invasion and blood borne metastasis. This makes prostate cancer formidable and dangerous.
Prostate Specific Antigen (PSA) is the screening test for this tumour. PSA is usually absent in the serum but increases significantly with local and systemic disease. Although PSA is prostate specific, its levels may peak during infection and benign enlargement of the prostate. Its because of the inability of PSA to help us differentiate benign from malignant disease of the prostate, PSA is mostly done as a screening test. Its elevation does not confirm a diagnosis of cancer. But marked elevation of this enzyme ( 10ng/ml) is a strong indicator of distant metastasis of the original tumour.
A prostate biopsy with the help of transrectal ultrasound (ultrasound images are taken by introducing the probe into the rectum), helps to procure small amounts of tissue from the prostate gland. Tissue is collected from several sites of the prostate gland for histopathological analysis. The stage and grade of the tumour can also be declared by performing a biopsy.
Mr Khalil was asking his family physician specifically about the role of a surgical intervention known as TURP or Transurethral Resection of Prostate; for the treatment of his fathers prostate tumour. It is good for family physicians and general practitioners to remember this simple fact that unless a cancerous growth is completely removed it is impossible to find a proper cure for the disease. TURP does not provide complete removal of the prostate gland and thus a radical prostatectomy is one of the definitive cures for prostate cancers. For senior citizens like Mr. Jalil (greater then 80 years of age) who may have other serious co morbid conditions, external beam radiation therapy is available in first world countries.
But it is imperative for doctors of all discipline to counsel patients about potential adverse effects which is common to radical prostatectomy and radiation therapy. Erectile dysfunction is one of the most common side effects of both radical prostatectomy and radiation therapy and patients who are in the early stage of cancer must be explained of this sad predicament with tact, delicacy and compassion.
If biopsy reveals malignancy with metastatic disease, the treatment options may seem grimmer. With efficacy and perseverance on part of medical personnel and caregivers, chances of prolonging life for patients like Mr. Jalil can be enhanced. Androgens are hormones which are chiefly responsible for the spread of cancer and the bulk of androgens are secreted from the testicles. Less then 5% of androgen is secreted from the adrenal gland which may be blocked by other hormonal antagonists.
Orchidectomy or castration helps to lower serum androgen levels significantly but it comes with side effects like development of breasts in male, impotence and other side effects.
Hormonal therapy essential for the blockade of androgen activity include drugs like exogenous oestrogen and Leutenizing Hormone Releasing Hormone (LHRH).
LHRH has lesser side effect then synthetic oestrogen and is available as subcutaneous implants or injections.
With early diagnosis and vigilance, first world countries like USA have been able to raise the chances of 5 year survival rate for prostate cancer to 99%. Proper history taking, clinical examination (most importantly digital rectal exam) and pathological techniques should enable us to reduce mortality and morbidity of prostate cancer in our country as well.
The writer can be reached at [email protected]
